Not all services require precertification.
The following are examples of services requiring precertification
before providing the following nonemergent or Urgent Care Services:
- Skilled Nursing Facility (SNF)
- Home Health Care
- Diagnostic tests, including but not limited to MRI, MRA, PET scans, etc.
- Hospital or ambulatory care center-based outpatient surgeries for certain procedures
- Elective inpatient admissions
- Referrals and services from noncontracted providers
- Durable Medical Equipment (DME)*
- Outpatient IV infusion or injectable medications
- Certain reconstructive procedures
- Occupational, speech and physical therapy
- Referrals outside of the IntegraNet network
- Requests for noncovered services under the Medicare program
- Inpatient Admissions
- Inpatient Rehabilitation
Examples of services that require the health plan to perform precertification, not IntegraNet:
- Inpatient mental health services
- Transplant services
- Behavioral health partial hospitalization
- Part D Drugs that require Authorization (also see 20 Prescription Drug Coverage)
Physician and nurse reviewers at IntegraNet Health use written criteria to assist in the determination of medical necessity. The following medical necessity criteria are used and available to contracted physicians and providers upon request:
- Centers for Medicare & Medicaid (CMS) National Coverage Determination (NCD)
- CMS Local Coverage Determination (LCD), when applicable
- For drugs and biologics, Medicare approved Drug Compendia
- Health Plan Clinical UM Guidelines and Behavioral Health UM Guidelines, when applicable
- AIM Specialty Health Guidelines for diagnostic imaging and sleep studies
- MCG (formally called Milliman Care Guidelines) if there are no existing Medicare policies available
Ensuring Appropriate Services and Coverage
In conjuction wih our health plan partners, IntegraNet Health is committed to covering out mutual plan members' care and encourage appropriate use of healthcare services. Physicians, providers and IntegraNet staff who make utilization-related decisions must comply with the following policies:
- Utilization management decisions are based on appropriateness of care, services, and existence coverage.
- IntegraNet Health does not compensate physicians, providers, or other individuals conducting utilization review for denials of coverage or services.
- IntegraNet Health does not provide financial incentives for utilization management decision-makers to encourage decisions that result in under-utilization.